Which assessment finding indicates that the nurse should take immediate action for an older patient?

Correct Answer: D

Rationale: The correct answer is D: Bilateral basilar crackles. This finding indicates fluid accumulation in the lungs, which can impede oxygenation and lead to respiratory distress in older patients. Immediate action is needed to address potential respiratory compromise. Weak cough effort (A) may also be concerning but does not require immediate action. Barrel-shaped chest (B) is associated with chronic obstructive pulmonary disease but does not warrant immediate intervention. Dry mucous membranes (C) may indicate dehydration but do not pose an immediate threat to the patient's health.

Correct Answer: C

Rationale: The correct answer is C because an oxygen saturation of 86% indicates severe hypoxemia, which can lead to tissue damage and organ dysfunction. The nurse should intervene immediately to improve oxygenation. A weak productive cough (Choice A) may indicate impaired airway clearance but does not require immediate intervention. Pleuritic chest pain (Choice B) is common in pneumonia but does not indicate an immediate threat to the patient's life. Coarse crackles in the lower lobes (Choice D) are typical findings in pneumonia but do not necessitate immediate action unless accompanied by severe respiratory distress.

Correct Answer: A

Rationale: The correct answer is A: Perform tracheostomy suctioning using sterile technique. This is the most appropriate action because thick secretions can obstruct the tracheostomy tube, leading to respiratory distress. Suctioning helps clear the airway and maintain patency. Sterile technique is crucial to prevent introducing infection. Incorrect Choices: B: Increasing oxygen flow does not directly address the issue of thick secretions in the tracheostomy tube. C: Instilling normal saline may further increase secretions and can potentially cause aspiration. D: Encouraging the patient to take deep breaths may not effectively clear the thick secretions from the tracheostomy tube.

Correct Answer: B

Rationale: The correct answer is B: Oxygen saturation of 85%. This assessment finding is most concerning because it indicates severe hypoxemia, which can lead to tissue damage and respiratory failure. A low oxygen saturation level of 85% requires immediate intervention to prevent further complications. Rationale: 1. Crackles heard in the lung bases (Choice A) are common in pneumonia but do not indicate severe hypoxemia. 2. Cough with yellow sputum production (Choice C) is a common symptom of pneumonia but does not directly reflect the patient's oxygenation status. 3. Respiratory rate of 22 breaths per minute (Choice D) is within the normal range and may not necessarily indicate severe respiratory distress. In summary, the oxygen saturation of 85% is the most concerning assessment finding as it directly reflects the patient's oxygenation status and requires immediate attention to prevent complications.

Correct Answer: B

Rationale: The correct answer is B: Spiral CT scan. This test is the priority for diagnosing pulmonary embolism as it provides quick and accurate visualization of blood flow in the lungs. Chest x-ray (A) may not show definitive signs of embolism. Pulmonary function test (C) measures lung function but does not directly diagnose embolism. Arterial blood gas analysis (D) may show respiratory status but does not confirm the presence of embolism. Spiral CT scan is the gold standard for diagnosing pulmonary embolism due to its high sensitivity and specificity.